The present invention relates to implantable cardiac stimulation devices.
It is the function of a pacemaker to provide electrical stimulation pulses to the appropriate chamber(s) of the heart (atria or ventricles) in the event that the heart is unable to beat of its own (i.e., in the event that either the sinoatrial node fails to generate its own natural stimulation pulses at an appropriate sinus rate, or in the event such natural stimulation pulses do not effectively propagate to the appropriate cardiac tissue). Most modern pacemakers accomplish this function by operating in a xe2x80x9cdemandxe2x80x9d mode where stimulation pulses from the pacemaker are provided to the heart only when the heart is not beating of its own, as sensed by monitoring the appropriate chamber of the heart for the occurrence of a P-wave or R-wave. If a P-wave or a R-wave is not sensed within a prescribed period of time (which period of time is usually referred to as the xe2x80x9cescape intervalxe2x80x9d), then a stimulation pulse is generated at the end of this prescribed period of time and delivered to the appropriate heart chamber via a pacemaker lead.
Modem pacemakers are generally of two types: i) single chamber pacemakers and ii) dual chamber pacemakers. In a single chamber pacemaker, the pacemaker provides stimulation pulses to, and senses cardiac activity within, a single chamber of the heart (either the right ventricle or the right atrium). In a dual chamber pacemaker, the pacemaker provides stimulation pulses to, and senses cardiac activity within, two chambers of the heart (e.g., both the right atrium and the right ventricle).
One of the most versatile programmable pacemakers available today is the DDDR pacemaker. This pacemaker represents a fully automatic pacemaker, which is capable of sensing and pacing both the atrium and the ventricle, and is also capable of adjusting the pacing rate based on one or more physiological parameters such as minute ventilation, heart contractility, QT interval and/or mechanical parameters such as activity and body acceleration.
Unfortunately, in some instances, a given patient may develop fast atrial rhythms which result from a pathologic arrhythmia such as supraventricular tachycardia, fibrillation or flutter. In these cases, patients who require DDD/DDDR pacing are limited by the potential for rapid ventricular pacing due to tracking of the atrium rhythm.
As these patients require atrioventricular synchrony during periods of sinus rhythm, attempts have been made in the art to prevent undesirable tracking of pathologic atrial arrhythmias by automatically switching the pacemaker""s mode of operation from an atrial tracking pacing mode to a non atrial tracking pacing mode.
Thus it would be desirable for the pacemaker to switch the pacing mode from an atrial tracking mode to a non atrial tracking mode only if a pathologic supraventricular arrhythmia is detected, thus avoiding repetitive mode switching based on fluctuations in the sensed atrial rate.
A variety of mode-switch algorithms have been developed to avoid inappropriate tracking of atrial arrhythmias and to provide tracking of the sinus node at all other times. The mode-switch algorithm differs from manufacturer to manufacturer and, at least at present, this is confusingly given different names, e.g., automatic mode-switching (AMS), or Atrial Tracking Response (ATR). Basically, these algorithms enable the pacemaker to change the mode of response to atrial sensed events from a tracking DDD(R) to a non tracking mode (VVI(R) or DDI(R)), when the intrinsic or average atrial rate exceeds a programmed switch rate.
One of the earliest mode switching devices, described in xe2x80x9cDual-demand pacing for refractory atrioventricular re-entry tachycardiaxe2x80x9d (Curry et al., PACE, Vol.2 (2), 1979, pp.137-151), was designed to pace at a fixed rate of 70 beats per minute, when sensed heart rates were either below this rate or above 150 beats per minute.
Typically, the threshold switch rate at which switching occurs is entered during programming of the pacemaker upon installation and remains fixed thereafter. This mode switching criterion may cause problems for patients who exhibit normal sinus tachycardia due to physical activity or emotional stress. Another difficulty associated with previous techniques is that mode switching occasionally occurred due to a single premature atrial contraction or fluctuations of atrial rhythm.
In the above instances, rates slightly exceeding the programmed switch rate are not indicative of a supraventricular arrhythmia. These patients may thus be subjected to undesirably frequent mode switching occurrences as their atrial rates slightly exceed and then drop below the programmed switch rate.
Consequently, algorithms have been developed for switching pacing modes which have the capability of determining an atrial rate representative of the actual atrial activity to enhance the chances of a correct detection of an atrial arrhythmia, thus avoiding a response based on a single premature atrial contraction or fluctuations of atrial rhythm above the programmed switch rate.
In U.S. Pat. No. 5,144,949, a dual chamber pacemaker is described with automatic mode switching between the DDD mode, the VVIR mode and DDDIR mode, based on the difference between the average sensor rate and the average atrial rate; whenever the sensor rate and the atrial rate are too different and the difference exceeds a programmable function of the two rates, the mode is switched to VVIR to avoid tracking high atrial rates.
In U.S. Pat. No. 5,549,649, a pacemaker is disclosed using a filtered atrial rate (FAR) as a basis for mode switching in order to reduce mode switching responses due, for example, to a single premature atrial contraction or fluctuations in the atrial activity. The FAR is obtained using a rate smoothing filter, which during each cycle limits the amount by which the FAR may change from cycle to cycle. This is accomplished by increasing the FAR by a programmable high rate factor when the intrinsic atrial rate increases, and by decreasing the FAR by a programmable low rate factor when the intrinsic atrial rate decreases.
The optimal use of mode switching was however found to be enhanced by allowing some variability in the programmed threshold mode switch rate on the basis of either new algorithms or measured values of sensed parameters. For these reasons, it is sometimes desired to provide pacemakers that can be programmed with a mode switching threshold rate calculating algorithm.
For example, U.S. Pat. No. 5,579,200 describes an algorithm for calculating the mode switch threshold rate as a function of the programmed base pacing rate. Because the base rate is typically a non-linear function of activity level, the threshold switching rate is also non linear and dependent on the activity level. The threshold switching rate can be equal to the base pacing rate plus a constant or can be some other, more complex function of the base pacing rate and/or activity level.
U.S. Pat. No. 5,713,928 discloses an algorithm to detect atrial arrhythmias, using a first window of atrial acceleration detection, whose duration is a function of the preceding atrial rhythm, for determined rapid atrial rhythm and a second window (Atrial Escape Interval) for a determined slow atrial rhythm, which allows the discrimination between atrial extrasystoles and physiological accelerations of the atrial rhythm.
U.S. Pat. Nos. 5,247,930 and 5,531,771 define a method for determining a so-called physiological rate, as a function of sensed atrial rate, and means for defining a range of atrial rates, the so-called physiological band, relative to and varying with the physiological rate.
As described in xe2x80x9cMode Switching for Atrial Tachyarrhythmiasxe2x80x9d (Sutton et al., American Journal of Cardiology Vol. 83, 1999, pp. 202D-210D), such mode switching features have been implemented in the pacemakers sold under the trade names Diamond II DDDR, Ruby II DDD and Saphir II VDDR by Vitatron Medical B. V., K I Dierxc3xa9n, the Netherlands.
In such devices the so-called physiological rate is a moving average of the intrinsic atrial rate while the physiological band is a fixed area of 15 beats/min higher and lower than the physiological rate, if mode switching is selected as automatic. Any atrial event outside this band is deemed pathologic and on a beat-to-beat basis a single premature atrial beat that occurs above the physiological band will not be tracked and the flywheel rate or the sensor rate determines the ventricular rate.
From the above, it is evident that the previously described automatic mode switching algorithms based on a programmable or sensor determined upper rate limits and the most recent pacing systems providing means for defining ranges of acceptable atrial rates are lacking in the capability of estimating the physiological processes that regulate the arrhythmogenesis and more specifically the control exerted by the Autonomic Nervous System (ANS).
Furthermore, another limitation of the previous described methods is represented by the inability to detect and control the breathing arrhythmias that arise as rapid variations of the sinus atrial rate; these arrhythmias could either be confused with the onset of a cardiac arrhythmia causing the activation of the mode switching or could be not considered if the range of the acceptable atrial rates is increased with the risk of a lack of sensitivity to possible cardiac arrhythmias.
Most clinicians agree that the balance of the sympathetic autonomic and parasympathetic autonomic nervous systems regulate, to some extent, the sinoatrial (SA) node and the atrioventricular (AV) node of the heart and, thus, largely influence the control of the heart rate. These two nervous systems operate somewhat reciprocally to effect changes in the heart rate; specifically an increase in heart rate can be associated directly with a momentary dominance of the sympathetic activity over the vagal activity, while a reduction of the heart rate can be associated directly with a momentary dominance of the vagal activity over the sympathetic activity.
In that respect, reference may be had to commonly assigned U.S. Pat. No. 5,645,570, where a method and an implantable device are disclosed to measure sympatho-vagal activity in a continuous manner and with time constants such as to allow the possible piloting of a pharmacological and/or electrical therapeutic action. Also, beat-to-beat fluctuations which occur around a person""s mean rate are known as heart rate variability (HRV) and are attributed, in part, to the non linear interaction between the two branches of involuntary nervous system.
The present invention thus has the object of providing an implantable heart stimulation system that overcomes the disadvantages outlined above. The present invention provides a dual chamber cardiac pacing system capable of switching from an atrial tracking mode of operation to a non-atrial tracking mode in response to the occurrence of an atrial arrhythmia.
Still more particularly, the present invention relates to a dual-chamber cardiac pacing system, comprising means for the automatic beat-to-beat adjustment of the Maximum Allowable Variation (MAV) of the sensed atrial rate as a function of the sympatho-vagal balance of the patient, switching from an atrial tracking mode to a non atrial tracking mode of operation when an atrial arrhythmia is detected.
In the presently preferred embodiment of the invention, an implantable dual-chamber pacemaker system is provided having means for an automatic beat-to-beat adjustment of the Maximum Allowable Variation (MAV) of the sensed atrial rate as a function of the sympatho-vagal balance, switching from an atrial tracking mode of operation (e.g., DDD or DDD(R)) to a non atrial tracking mode (e.g., VDI or VDI(R)) when either an arrhythmic tachycardic rate, exceeding the MAV, or a sinus tachycardic rate, exceeding the maximum tracking atrial rate (MTAR) is detected. Thus the invention is essentially based on the recognition that automatic mode switching systems and algorithms can determine their dynamic decisions of switching from an atrial tracking mode to a non atrial tracking mode in response to variations of the sympatho-vagal balance.
The system of the invention preferably provides logic means for continuously determining the atrial rate variation (xcex94AR) and the MAV, whereby the MAV defines the upper limit for xcex94AR above which tracking is not allowed, discriminating between physiological rate variations and arrhythmic variations.
Still preferably, the system of the invention further includes the capability of returning to an atrial tracking mode of operation, when the atrial rate variation (xcex94AR) remains under the MAV for a definite number of cycles.
In a preferred embodiment, the sympatho-vagal balance is expressed by a proper index of HRV. Still preferably, that index is the number of atrial intervals, which in a predetermined time interval or number of beats differ from the preceding interval by more than a predetermined quantity. In preferred embodiments, the captioned number of beats is 100, the time interval is one minute and/or the predetermined quantity is 50 milliseconds (ms).
In one aspect, this invention is an implantable heart-stimulation system, comprising a first sensing element configured to sense atrial signals; a second sensing element configured to sense ventricular signals; a pulse generator configured to generate atrial and ventricular stimulating signals; and a control unit configured to determine for each cardiac cycle an atrial rate from the sensed atrial signals, to determine for each cardiac cycle a maximum allowable variation of the atrial rate as a function of sympatho-vagal balance, and to switch from an atrial tracking pacing mode to a non-atrial tracking pacing mode when a variation in the atrial rate between a first cardiac cycle and a second cardiac cycle exceeds the maximum allowable variation.
The sympatho-vagal balance may be expressed by heart rate variability and the heart rate variability may be measured by means of an index. The index may be calculated as the number of atrial intervals, which in a predetermined time interval or number of beats differ from the preceding interval more than a predetermined quantity. The maximum allowable variation of the sensed atrial rate may be a positive linear function of an index of the sympatho-vagal balance. The control unit may be configured to determine for each cardiac cycle an estimated atrial rate and wherein the control unit is configured to calculate the variation in the atrial rate as the difference between the sensed atrial rate of a present cardiac cycle and the estimated atrial rate of the previous cardiac cycle. The estimated atrial rate may be a moving average rate calculated at each cycle. The control unit may be programmable.
In a second aspect, this invention is a method of controlling the pacing mode of a heart stimulation system implanted in a patient, the system including first and second sensors for sensing atrial and ventricular signals, a pulse generator for generating and providing atrial and ventricular stimulation pulses to the patient""s heart and a control unit for controlling the pacing mode of the system, the method comprising determining in the control unit an atrial rate of the patient""s heart from the sensed atrial signals; determining in the control unit a maximum allowable variation of the atrial rate for each cardiac cycle as a function of sympatho-vagal balance; and switching from an atrial tracking pacing mode to a non-atrial tracking pacing mode when a variation in atrial rate from a first cardiac cycle to a second cardiac cycle exceeds the maximum allowable variation.